WHO reform and global health

Radical restructuring is the only way ahead

Fiona Godlee, Assistant editora

aBMJ, London WC1H 9JR

The world has changed since the World Health Organisation was founded nearly 50 years ago, and the pressure on WHO to change in response has never been greater. Continuing financial constraints, growing demands on the international health system, the approach of the millennium (the deadline for the Health for All initiative), and the certainty of new leadership (see p 1367)1 in 1998, when WHO celebrates its own half century, all add to the urgency and timeliness of the debate. But what would a reformed WHO look like, and will reform mean dismantling the existing organisation and starting again? The meeting this week of the World Health Assembly in Geneva marks the beginning of a crucial year for the future of international health.

The past five years have seen the emergence of an impressive consensus about the problems of the world's health system. Analysts talk of a crisis in international health, with increasing inequities and worsening access to health care for the world's most vulnerable populations. The moves towards privatisation and tertiary care are mirrored by reduced emphasis on and provision of primary and preventive care. Lack of coordination between international agencies has meant duplication of effort, confusion, and waste of resources.

With its narrow, top down, service oriented approach to health and its centralised, hierarchical bureaucracy, WHO has proved unequal to the new challenges. Its once clear calls for equity and universal primary care have been drowned out by the World Bank's conflicting emphasis on economic growth and efficiency. Much of this can be blamed on WHO's lack of leadership and inadequate commitment from member states. In trying to please all its political constituents WHO has spread itself too thin and lost direction.2

The first formal call for reform came from within WHO in 1993,3 but since …